CDI in the news: Vaping-related lung injury

By Emmel Golden, MD, FCCP, CCDS

Vaping-related lung injuries are currently on the rise. The occurrence of serious and even fatal lung disease associated with vaping has been reported this year, with an increasing number of cases in the last few months. The specific agent or agents responsible have not yet been identified. The reports to date are mostly about patients hospitalized with vaping related lung disease.

The typical patient is a 19-year-old male. Related symptoms develop over days to weeks. On presentation the patients typically complain of shortness of breath, hemoptysis, fever, and chest pain. Additionally, gastrointestinal symptoms are very common. Chest x-rays and CT scans of the thorax are abnormal, demonstrating infiltrates in both lungs. The presentation is similar to a pneumonia. The diagnosis is established based on the history of vaping and the exclusion of other causes of the lung  condition, particularly, an infection. Some of the patients may have a coexistent infection in addition to the vaping-related injury.

For HIM and CDI professionals, the challenge is identifying supportive documentation in the medical record and assigning the most applicable code possible for  this recently recognized lung condition. Communication with providers is the key to secure the documentation that will support a known or suspected case of vaping-related lung disease. There is no official guidance regarding the coding of vaping-related lung disease. However, based on our interpretation, using the Alphabetic Index and Tabular List, descriptive codes exist that capture vaping-related lung disease.

When vaping-related lung disease are identified, most of the appropriate codes can be found in the J68 category, J68: Respiratory conditions due to inhalation of chemicals, gases, fumes, and vapors. This describes conditions applicable to vaping-related lung disease. It is the vapor, generated by the device, that delivers the responsible chemicals to the lung. At this time the specific chemical or combination of chemicals that cause the lung injury have not been identified. The most common condition being identified in these hospitalized patients is vaping-related pneumonitis. However, the specific condition identified by the provider will determine the precise code selected within J68 and a query may be needed to identify the specific disease being treated. For example:

• Vaping-related pneumonitis: J68.0
• Vaping-related pulmonary edema: J68.1
• Vaping-related condition, unspecified: J68.9

Under J68 is an instruction note to,  “Code first (T51 – 65) to identify cause.” Therefore, in these cases, the appropriate T-code will be coded before the code identifying the specific complication. This T-code will be sequenced as principal diagnosis if the vaping-related lung disease is the chief reason for admission. At this time, the correct code in the T51 – T65 range to apply is T59.891-:Toxic effect of other specified gases, fumes, and vapors, accidental.

These patients may have other respiratory conditions that will need to be coded. For example, acute hypoxic respiratory failure and pneumonias that are either present at the time of admission or develop in the hospital. The most critically ill patients may have Acute Respiratory Distress Syndrome (ARDS) and require  mechanical ventilation. One patient has been supported on peripheral ECMO.

Lipid filled macrophages have been recovered in some of the patients who have had a  bronchoalveolar lavage or lung biopsy. These patients have been diagnosed with a very specific type of pneumonitis, called Lipid pneumonia. This may be related to the use of vitamin E, an oil, in the vaping compounds. Lipid pneumonia related to vaping has a specific code that is not within the J68 category, J69.1: Pneumonitis due to inhalation of oils and essences. There is a code first note to use a code in the T51 – T65 range, with J69.1 as well.

Currently, we are dealing with the acute manifestations of a lung disease caused by vaping. It is possible that chronic conditions will be recognized in the survivors of the acute vaping-related lung disease. As we learn more, the CDI and HIM community will be required to keep up with both the clinical and coding challenges associated with this new, and hopefully limited  lung condition.

References:

• Layden, J. E., Ghinai, I., Pray, I., Kimball, A., Layer, M., Tenforde, M., … Meiman, J. (2019). Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1911614
• Outbreak of Lung Injury Associated with E – Cigarette Use, or Vaping. (September 19,2019) Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

Editor’s note: Golden is the chief clinical officer at Enjoin in Eads, Tennessee. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries. Contact ACDIS Editor Linnea Archibald (larchibald@acdis.org) with any questions. Please note that the ACDIS CDI Regulatory Committee is also working on guidance on this topic.